Dementia is not a single disease.  Dementia is a family of diseases that cause progressive memory loss, usually in older patients.  The most common cause of dementia is Alzheimer’s disease.  Dementia is progressive, and while some treatments exist, their efficacy is only modest.  In addition to memory loss, patients frequently suffer personality and behavior changes.

Dementia is common, affecting 3.4 million Americans as of 2002, and this number is sure to increase as our population ages.

The most difficult problem in the management of dementia is managing the agitation and hallucinations that patients frequently experience.  Besides being obviously disturbing to the patients, agitation and psychotic symptoms contribute significantly to caregiver stress and burnout.  It’s no surprise then that antipsychotic medication – medication developed for use in patients with schizophrenia and other psychotic disorders – has a long history of use in patients with dementia.  There’s only one problem; they don’t work.

Randomized studies have shown that patients with dementia and psychotic symptoms are no more calmed by antipsychotic medication than by placebo.  Worse than that, in elderly patients some antipsychotic medications increase the risk of stroke.

Despite this evidence, faced with an agitated patient with dementia, many physicians (sometimes me included) out of desperation reach for an antipsychotic medication.  A New York Times article last week summarized the controversy well.

There are therapies that have been proven to help with agitation in patient with dementia, but they’re not medicines.  The therapies are behavioral: calmly redirecting the patient, reorienting him to where he is, distracting him with a less stimulating activity, etc.  This is more effective but requires more caregiver time, a resource that will certainly become scarcer in the future.  Unless better treatments are developed, caring for dementia patients will become increasingly challenging in the next decades.

(Thanks to Michelle H. for sending me the article.)

Learn More:

New York Times article: Doctors Say Medication Is Overused in Dementia

Neuroepidemiology article: Prevalence of Dementia in the United States

Tangential Miscellany:

Two years ago I wrote about the looming shortage of primary care doctors and their increasing dissatisfaction with the practice of medicine.  A New York Times article last week reiterates the point that a lot of doctors no longer enjoy what they do:  Eyes Bloodshot, Doctors Vent Their Discontent.

This week, a large national survey of physicians’ use of electronic health records (EHRs) was published in the New England Journal of Medicine.  The results generated a lot of attention in the general media.

The good news is that physicians with EHRs are largely very satisfied with them and believe that EHRs improve patient care.  The bad news is that nationally only 4% of doctors use EHRs.  The largest barrier cited as preventing physicians from adopting EHRs is the expense.

In any other industry, that would be unthinkable.  Imagine if a hotel came up with an easier way for guests to make a reservation.  If the new technology was very expensive, only those hotels with the most resources would be able to afford it initially.  But eventually the price of the new technology would drop and almost all hotels would use it.  Within a few years the older way of making reservations would be gone.  That’s why you can’t listen to an LP record anymore or find a public phone booth or send a telegram.  Better technology spreads like wildfire through a marketplace, regardless of how expensive it is initially.

So if EHRs are better for patients, why the slow adoption?  For that matter why haven’t CT scans dropped in price?  Or pacemakers or MRIs?  Most medical technology should be dirt cheap.  My son’s laptop is much more powerful than the desktop PC I had in high school and cost less.

The answer is that the insurance model corrupts the incentives that work in other marketplaces.  By fixing the price for care, insurance companies make it impossible for doctors to make more money by providing better care.  Doctors in the insurance model can only make more by seeing more patients.  In such a system there’s no reason to invest in an EHR, because the investment will not lead to increased revenue.

The same perverse incentives keep prices high.  Since the insurance company sets the price for a CT scan, there’s no incentive to drop the price for a CT to compete against other providers.  The incentive is to get as many patients through the scanner as possible.  So while Dell keeps making better computers cheaper, CT scan prices stay the same.

Now academicians and lobby groups are clamoring for insurance companies and government to pay doctors to adopt EHRs.  But insurance companies and government got us in this mess.  Having them subsidize EHRs misses the point, and would keep EHRs expensive forever, like CTs.

A few doctors dedicated to excellent care have already taken the financial risk to invest in an EHR.  Some of us have abandoned our relationship with insurance companies so that we can work for our patients.  Some patients who are also discriminating consumers have looked for such physicians and are willing to pay more to see them.  More doctors and patients, increasingly dissatisfied with the insurance model, will hear about us and follow our lead.  That’s the solution.

Learn more:

New York Times article:  Most Doctors Aren’t Using Electronic Health Records

New England Journal of Medicine article:  Electronic Health Records in Ambulatory Care — A National Survey of Physicians

In February I wrote about the results of the ACCORD trial, a study designed to test whether strict glucose control in patients with diabetes helps prevent strokes and heart attacks and prolongs life.  The startling results were that the patients with diabetes who were randomized to have their glucose lowered to normal levels died sooner than those with more lax sugar control.

This week the New England Journal of Medicine published the results of another study, the ADVANCE trial, which was designed to answer the same question.  Over eleven thousand patients with type 2 diabetes were randomized to two groups.  One group was managed intensively with a goal of normal blood glucose.  The second group had less strict sugar control.  The groups were followed to measure the frequency of strokes, heart attacks, worsening of kidney disease, diabetic eye disease and death.

Again, in this trial, strict sugar control did not save any lives (though at least, it didn’t cause extra deaths like in ACCORD).  Strict sugar control also didn’t prevent strokes, heart attacks or eye disease.  The one benefit that was detected was that patients with strict control had less kidney disease than patients with lax sugar control.

The common theme seems to be that normal sugars are not the goal of diabetic treatment, or at least not the only goal.  Heart attack and stroke prevention in patients with diabetes involves many other proven therapies like smoking cessation, cholesterol lowering with statins, blood pressure medications and aspirin.

Learn More:

My post in February about the ACCORD trial:  What We Don’t Know About Diabetes

The New England Journal article publishing the results from the ADVANCE trial:  Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes

The New England Journal article publishing the results from the ACCORD trial:  Effects of Intensive Glucose Lowering in Type 2 Diabetes

Tangential Miscellany:

I hope us dads all get to spend some time with our kids this weekend, and all of us who are fortunate enough to still have our fathers in our lives have a chance to express our love and gratitude for everything they’ve done for us.  Happy Father’s Day!

As summer approaches, researchers at Auburn University have performed a study demonstrating the dangers of that ubiquitous summer accessory, the flip-flop.  They recruited volunteers and recorded their gait in both sneakers and flip-flops.  In flip-flops the subjects took shorter steps and didn’t raise their toes as far as they did in sneakers.

This makes sense, if you think about it.  When we wear flip-flops we curl our toes down to keep the sandals from flying off our feet.  This keeps us from taking a long step and also has our heel hit the ground at the wrong angle for optimal walking.

The investigators warn that this abnormal gait could contribute to foot and knee pain in people who walk long distances in flip-flops.  I’m sure this news ruins your day, if not your summer, but don’t despair.  The authors reassure us that wearing them for short distances like around the pool should be fine.

So when you see me at the beach in my wingtips, now you’ll know why.

Learn More:

ABC News article: Flip-Flops Can Cause Long-Term Health Problems

New York Times Health blog: Summer Flip-Flops May Lead to Foot Pain

Tangential Miscellany:

This week, I’d like to leave you with the eloquent rant of my patient Stephen J. who emailed me to vent about the problems with medical insurance.  I couldn’t have said it better.

Reason 4,327,602 to be critical of health insurance: “The Ticket Punch.”

Here is how it works.  Medical insurance companies pay by the visit.  Doctors need volume.  When a patient visits a doctor with a new complaint the doctor may need to “waste time” errr “spend time” diagnosing the problem.  The flat payment doesn’t cover the time.  So when the doctor sends the patient for an MRI, reviews the MRI and concludes that the patient should see a surgeon, he makes the patient come in before telling him that.  The patient would be better off to hear that in a phone call.  The other patients in the crowded waiting room would be better off too but the doctor can’t bill for the call and needs to “punch his ticket” in order to be paid.

Doctor’s used to validate parking; now patients punch billing chits for doctors.

I like the idea that a doctor can value a patient’s time and be paid to do so.  And I like parking validations.